Gestational Diabetes. Just the Facts Diabetes is the most common metabolic disorder of pregnancy 3-5% of all pregnancies Affects more than 150,000 pregnancies.

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Presentation on theme: "Gestational Diabetes. Just the Facts Diabetes is the most common metabolic disorder of pregnancy 3-5% of all pregnancies Affects more than 150,000 pregnancies."— Presentation transcript:

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Gestational Diabetes

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Just the Facts Diabetes is the most common metabolic disorder of pregnancy 3-5% of all pregnancies Affects more than 150,000 pregnancies each year More than 7,000 are of women with Type 1 diabetes 0.2 %-0.3 % of all pregnancies are complicated by pre-existing diabetes more than 2 % of women of childbearing age have unrecognized Type 2 diabetes

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Onset of first recognition during pregnancy A1 - controlled by diet and exercise A2 – controlled by insulin Up to 3-7 % will develop Type 1 within 1 year Up to % will develop overt diabetes at 7-10 years post partum unless lean & fit – 25 % risk Gestational Diabetes affects 3-14 % of all pregnancies and is one of the most common complications of pregnancy Results in 200,000 cases annually Just the Facts - continued

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Age < 25 Weight normal before pregnancy Member of an ethnic group with a low prevalence of GDM No known diabetes in first-degree relatives No history of abnormal glucose tolerance No history of poor obstetric outcome Low Risk For GDM

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Previous history of GDM Neonatal course complicated by hypoglycemia Classic diabetes symptoms Marked obesity (>120%IBW or > 27 BMI) Glycosuria Strong family history of diabetes Glucose screening as soon as feasible, if negative, retest wks of gestation* High Risk For GDM

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Maternal blood glucose levels are sustained longer to CHO load in pregnant state than in non-pg state Rising levels of contra-insulin hormones modify maternal utilization of glucose and amino acids Glucose homeostasis is maintained by an exaggerated rate and amount of maternal insulin release accompanied by decreased insulin sensitivity due to placental hormones Diabetogenic

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Are you willing to check your blood sugar after meals? Are you willing to eat in the morning? Are you willing to change your breakfast choices from cold cereal to whole grain toast & egg? Can you replace soda with water? Goal Setting

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After reviewing blood sugars and food log you notice that 2 hour post-prandial BG are out of goal range. You might discuss food choices, portions, glycemic index. Carbohydrate consistency or carbohydrate counting may be in order. You might make recommendations on reducing meal size, changing content to help post prandial BG. Intervention

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Currently, oral hypoglycemic agents are not recommended by the ADA or ACOG. The older sulfonylureas chlorpropamide and tolbutamide could cross the placenta, stimulate the fetal pancreas, and cause fetal hyperinsulinemia. However, the transfer of glyburide, a second-generation sulfonylurea across the human placenta was insignificant in experimental models. This finding led to a clinical trial of 404 women with GDM randomized to either glyburide or insulin therapy at weeks of gestation. There were no significant differences in glycemic control or adverse fetal outcomes. In addition, glyburide was not detected in the cord serum of any infants in the glyburide group. Oral Agents

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Smaller studies have also supported the safety of glyburide use in pregnancy. In one of these trials, women with GDM who were treated with glyburide had fewer asymptomatic hypoglycemic episodes compared to women with GDM treated with insulin, although the clinical significance of these hypoglycemic episodes is unknown. Thus, although glyburide appears to be safe in pregnancy based on the above studies, it is important to recognize that these studies in aggregate are small and not adequately powered to detect clinically important, relatively rare outcomes in pregnancy. Furthermore, glyburide is considered to be in Pregnancy Category C by the FDA, and therefore is not currently recommended by the ADA or ADOG until larger studies confirm its safety. Another potential concern with the use of glyburide in GDM is possible impairment of myocardial ischemic pre-conditioning. Oral Agents- Continued

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Currently, oral hypoglycemic agents are not recommended by the ADA or ACOG. The older sulfonylureas chlorpropamide and tolbutamide could cross the placenta, stimulate the fetal pancreas, and cause fetal hyperinsulinemia. However, the transfer of glyburide, a second-generation sulfonylurea across the human placenta was insignificant in experimental models. This finding led to a clinical trial of 404 women with GDM randomized to either glyburide or insulin therapy at weeks of gestation. There were no significant differences in glycemic control or adverse fetal outcomes. In addition, glyburide was not detected in the cord serum of any infants in the glyburide group. Oral Agents-continued

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Maternal glycemic status should be reclassified 6 weeks or more after pregnancy ends and every 3 years thereafter as either diabetes mellitus, impaired fasting glucose tolerance, or normolglycemia. Normal values for a 2-hour OGTT are fasting < 100 mg/dl. All patients with a history of GDM should be educated about MNT, exercise, maintenance of normal body weight, the need for family planning, and symptoms suggestive of hypoglycemia. Postpartum Considerations

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GDM is a common medical problem that results from an increased severity of insulin resistance as well as an impairment of the compensatory increase in insulin secretion. Pregnancy, in essence, serves as a metabolic stress test and uncovers underlying insulin resistance and B-cell dysfunction. GDM is associated with a variety of maternal and fetal complications, most notably macrosomia. Controversy surrounds the ideal approach for detecting GDM, and the approaches recommended for screening and diagnosis are largely based on expert opinion. Controlling maternal glycemia with MNT, close monitoring of blood glucose levels, and treatment with insulin if blood glucose levels are not at goal has been shown to decrease fetal and maternal morbidities. In addition, certain types of exercise appear to have potential benefits in women without any contraindications. Conclusion

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Other treatment modalities, such as oral agents, need further study to validate their safety and efficacy. Additionally, more research on the use of antepartum fetal assessment to help guide treatment in women with GDM is needed. Finally, postpartum management of women with GDM is critical because of their markedly increased risk of type 2 diabetes in the future. Conclusion - Continued